Primary Total Joint Arthroplasty Research Articles

Corticosteroids in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society

The American Association of Hip and Knee Surgeons (AAHKS), The American Academy of Orthopaedic Surgeons (AAOS), The Hip Society, The Knee Society, and The American Society of Regional Anesthesia and Pain Medicine (ASRA) have worked together to develop evidence-based guidelines on the use of corticosteroids in primary total joint arthroplasty (TJA). The purpose of these guidelines is to improve the treatment of primary TJA patients and reduce practice variation by promoting a multidisciplinary, evidence-based approach to the use of corticosteroids following primary TJA.

Ketamine in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society

The American Association of Hip and Knee Surgeons (AAHKS), The American Academy of Orthopaedic Surgeons (AAOS), The Hip Society, The Knee Society, and The American Society of Regional Anesthesia and Pain Medicine (ASRA) collaborated to develop evidence-based guidelines on the use of ketamine in primary total joint arthroplasty (TJA). The purpose of these guidelines is to improve the treatment of primary TJA patients and reduce practice variation by promoting a multidisciplinary, evidence-based approach to the use of ketamine in primary TJA.

Periarticular Injection in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society

The American Association of Hip and Knee Surgeons (AAHKS), The American Academy of Orthopaedic Surgeons (AAOS), The Hip Society, The Knee Society, and The American Society of Regional Anesthesia and Pain Medicine (ASRA) have worked together to develop evidence-based guidelines on the use of periarticular injection in primary total joint arthroplasty (TJA). The purpose of these guidelines are to improve the treatment of primary TJA in patients and reduce practice variation by promoting a multidisciplinary, evidence-based approach for the use of periarticular injection in primary TJA.

Rates and Outcomes of Periprosthetic Joint Infection in Persons Who Inject Drugs

BackgroundThe risk of periprosthetic joint infection (PJI) is higher in persons who inject drugs (PWID) after total joint arthroplasty (TJA), though reported rates vary widely. This study was designed to assess outcomes of TJA in PWID and to describe factors associated with improved PJI outcomes among PWID. MethodsA retrospective matched cohort study was performed using a 1:4 match among those with and those without a history of injection drug use (IDU) undergoing TJA. Demographic, surgical, and outcome variables were compared in multivariate logistic regressions to determine PJI predictors. Kaplan-Meier analyses were constructed to characterize the difference in survival of patients who did not have PJI or undergo joint explantation between PWID and the matching cohort. ResultsPWID had a 9-fold increased risk of PJI compared to the matched cohort (odds ratio 9.605, 95% CI 2.781-33.175, P < .001). Ten of 17 PWID whose last use was within 6 months (active use) of primary TJA had a PJI, while 7 of 41 PWID who did not have active use developed a PJI. Of PWID with PJI, treatment failure was seen in 15 of 17, while in patients who did not have an IDU history, 5 of 8 with PJI had treatment failure. ConclusionIDU is a significant risk factor for PJI following TJA. Future work investigating the effect of a multidisciplinary support team to assist in cessation of IDU and to provide social support may improve outcomes and reduce morbidity in this vulnerable population.

Preoperative High Sleep Quality Predicts Further Decrease in Length of Stay after Total Joint Arthroplasty under Enhanced Recovery Short-stay Program: Experience in 604 Patients from a Single Team.

ObjectiveTo investigate the safety, efficiency and cost of total joint arthroplasty (TJA) under the enhanced recovery after surgery (ERAS) program and identify predictors facilitating further decrease in length of stay (LOS).MethodsWe retrospectively collected the information of patients who underwent primary unilateral TJA by a single surgical team between January 2017 and June 2019. A total of 604 patients with LOS ≤ 3 was enrolled in this study. All patients completed 12‐month or longer follow‐up. Patients received the same ERAS protocol, mainly including preoperative preparation (patient education, preoperative functional exercises, nutritional support), blood management, pain management, sleep management, prevention of infection, prevention of thrombosis and strict discharge criteria. Preoperative characteristics of patients were collected from the medical record system and were compared between the LOS ≤ 2 group and the LOS = 3 group. Factors with significant difference were included in multivariate logistic regression analysis to find independent preoperative predictors for LOS. Joint function at the latest follow‐up, adverse events rate and hospitalization costs were compared between the LOS ≤ 2 group and the LOS = 3 group.ResultsOf the enrolled 604 patients, 271 patients (44.9%) had a LOS of 2 days or less while 333 patients (55.1%) had a LOS of 3 days. Pittsburgh Sleep Quality Index score (odds ratio [OR] = 1.084, 95% confidence interval [CI] = 1.024–1.147, P = 0.005), preoperative albumin level (OR = 0.945, 95% CI = 0.905–0.988, P = 0.012), digestive diseases (OR = 1.084, 95% CI = 1.024–1.147, P = 0.005) and total hip arthroplasty (THA) (OR = 0.273, 95% CI = 0.170–0.439, P < 0.001) were predictors of LOS ≤ 2 in the multivariate logistic analysis model. The postoperative joint function scores and adverse event rates were comparable between the LOS ≤ 2 group and the LOS = 3 group. The hospital costs were lower in the LOS ≤ 2 group than the LOS = 3 group.ConclusionUnder the rigorous ERAS program, 2‐day discharge in unselected TJA patients can be routinely applied. Patients with high preoperative sleep quality, high preoperative albumin level, free of digestive disease and undergoing THA procedure are more likely to be discharged within 2 days.

Causes and predictors of failed same-day home discharge following primary hip and knee total joint arthroplasty: a Canadian perspective.

Same-day home (SDH) discharge in total joint arthroplasty (TJA) has increased in popularity in recent years. The objective of this study was to evaluate the causes and predictors of failed discharges in planned SDH patients. A consecutive cohort of patients who underwent total knee (TKA) or total hip arthroplasty (THA) that were scheduled for SDH discharge between 01 April 2019 and 31 March 2021 were retrospectively reviewed. Patient demographics, causes of failed discharge, perioperative variables, 30-day readmissions and 6-month reoperation rates were collected. Multivariate regression analysis was undertaken to identify independent predictors of failed discharge. The cohort consisted of 527 consecutive patients. 101 (19%) patients failed SDH discharge. The leading causes were postoperative hypotension (20%) and patients who were ineligible for the SDH pathway (19%). 2 individual surgeons, later operative start time (OR 1.3; 95% CI, 1.15-1.55; p = 0.001), ASA class IV (OR 3.4; 95% CI, 1.4-8.2; p = 0.006) and undergoing a THA (OR 2.0; 95% CI, 1.2-3.1, p = 0.004) were independent predictors of failed SDH discharge. No differences in age, BMI, gender, surgical approach or type of anaesthetic were found (p > 0.05). The 30-day readmission or 6-month reoperation were similar between groups (p > 0.05). Hypotension and inappropriate patient selection were the leading causes of failed SDH discharge. Significant variability existed between individual surgeons failed discharge rates. Patients undergoing a THA, classified as ASA IV or had a later operative start time were all more likely to fail SDH discharge.

Low-Dose Aspirin for Venous Thromboembolism Prophylaxis is Associated With Lower Rates of Periprosthetic Joint Infection After Total Joint Arthroplasty

BackgroundAspirin as a venous thromboembolism (VTE) prophylactic agent has been shown to have antistaphylococcal and antibiofilm roles. Optimal acetylsalicylic acid (ASA) dosage would facilitate antimicrobial effects while avoiding over-aggressive inhibition of platelet antimicrobial function. Our purpose was to determine the periprosthetic joint infection (PJI) rate after total joint arthroplasty in patients receiving low-dose ASA (81 mg twice a day), in comparison to high-dose ASA (325 mg twice a day). MethodsWe conducted a retrospective cohort study between 2008 and 2020. Eligible patients were older than 18 years, underwent primary total joint arthroplasty, both total knee arthroplasty and total hip arthroplasty, had a minimum 30-day follow-up, and received a full course ASA as VTE prophylaxis. Patients’ records were reviewed for PJI, according to Musculoskeletal Infection Society criteria. Patients were excluded if they underwent revision arthroplasty, had a history of coagulopathy, or had an ASA regimen that was not completed. In total 15,825 patients were identified, 8,761 patients received low-dose ASA and 7,064 received high-dose ASA. ResultsThe high-dose cohort had a higher PJI rate (0.35 versus 0.10%, P = .001). This relationship was maintained when comparing subgroups comprising total knee arthroplasty (0.32 versus 0.06%, P = .019) or total hip arthroplasty (0.38 versus 0.14%, P = .035) and accounting for potentially confounding demographic and surgical variables (odds ratio = 2.59, 95% CI = 1.15-6.40, P = .028). ConclusionComparing low-dose to high-dose ASA as a VTE prophylactic agent, low-dose ASA had a lower PJI rate. This may be attributable to a balance of anti-infective properties of ASA and antiplatelet effects.

Postoperative Acute Kidney Injury With Dual NSAID Use After Outpatient Primary Total Joint Arthroplasty.

NSAIDs have been shown to be highly effective analgesic agents in the postoperative period. NSAIDs do have several potential adverse effects, including kidney injury (AKI). Little is known about AKI in the outpatient total joint arthroplasty (TJA) setting, where patient labs are not closely monitored. The objective of this study was to evaluate the renal safety of combined use of ibuprofen for pain control and aspirin for deep vein thrombosis chemoprophylaxis after outpatient primary TJA. Patients undergoing primary total hip or total knee arthroplasty between January 2020 and July 2020 at a single center were included for analysis. All included patients were discharged on a standard regimen including aspirin 81 mg twice a day and ibuprofen 600 mg three times a day. Patients were ordered a serum creatinine test at 2 and 4 weeks postoperatively. Patients with postoperative acute kidney injury were identified per Acute Kidney Injury Network criteria. Between January 23, 2020, and August 30, 2020, 113 patients were included in this study, of whom creatinine levels were measured in 103 patients (90.3%) at the 2-week postoperative time point, 58 patients (50.9%) at the 4-week time point, and 48 (42.1%) at combined 2- and 4-week time points. Three patients (2.9%) were found to have an AKI. This study found a rate of AKI of 2.9% with the use of dual NSAID therapy postoperatively after primary TJA. All cases occurred at 2 weeks postoperatively and saw spontaneous resolution.

Postoperative outcomes of mepivacaine vs. bupivacaine in patients undergoing total joint arthroplasty with spinal anesthesia

BackgroundSpinal anesthesia (SA) has been previously associated with improved outcomes after total joint arthroplasty (TJA). The purpose of this study was to compare outcomes between various local anesthetics.MethodsThis was a retrospective study of 1,328 patients undergoing primary TJA with SA from September 2020–2021 at a single institution. Patients were grouped based on TKA or THA and further separated and analyzed in terms of anesthetic agents—mepivacaine (M), hyperbaric bupivacaine (HB), or isobaric bupivacaine (IB). Subgroup analysis of same-day-discharge (SDD) patients and low- (<11 mg) and high-dose bupivacaine was performed. Statistical significance was assessed at P<0.05.ResultsMepivacaine use was associated with younger age, lower ASAs, and lower Charlson Comorbidity Index (CCI) scores in both THAs and TKAs. Postoperatively, significant differences were found between HB, IB, and M in LOS, the first PT ambulation distance and rates of SDD, and home discharge in both THAs and TKAs. No significant differences in outcomes were observed between high- and low-dose bupivacaine in THAs or TKAs. In SDD patients, a significant difference was found only in the first 6-clicks mobility scores. After controlling for age, BMI, sex, ASA, and procedure type, mepivacaine was found to be associated with shorter LOS, increased likelihood of SDD, home discharge, POD-0 ambulation, and, further, the first ambulation distance. No significant differences were observed in 6-clicks mobility scores, urinary retention, 30-day ED returns or 30-day readmissions.ConclusionsBoth bupivacaine and mepivacaine are safe and effective local anesthetics for patients undergoing TJA as evidenced by low, similar rates of urinary retention and 30-day ED returns and readmissions. Mepivacaine does appeared to facilitate early ambulation, shorter LOS and home discharge and should be considered as the local anesthetic of choice for patients undergoing rapid recovery TJA.

Chlorhexidine gluconate lavage during total joint arthroplasty may improve wound healing compared to dilute betadine

PurposeIntraoperative wound irrigation prior to closure during total joint arthroplasty (TJA) is an essential component of preventing infections and limiting health care system costs. While studies have shown the efficacy of dilute betadine in reducing infection risk, there remains concerns over its safety profile and theoretical inactivation by blood and serum. This study aims to compare infection and wound complications between chlorhexidine gluconate (CHG) and betadine lavage during TJA.MethodsAll primary TJA between 2019–2021 were analyzed at a single institution, and periprosthetic joint infection (PJI), wound drainage, 30 and 90-day emergency room (ER) readmission due to wound complications, aseptic loosening, and revision surgery rate were compared between patients undergoing intraoperative CHG versus betadine lavage prior to closure. Baseline demographics were controlled, and multivariate logistic regression was performed to compare complication rates.ResultsA total of 410 TJA, including 160 hip and 250 knee arthroplasties were included. Compared to the dilute betadine cohort, all TJA patients undergoing CHG lavage had a statistically significant lower 30 and 90-day emergency room readmission rate due to wound complications. Both hip and knee arthroplasty patients with CHG had a statistically significant lower rate of postoperative superficial drainage and dressing saturation at clinic follow-up, but only knee arthroplasty patients had significant decreased readmission rate for incisional wound vacuum placement and close inpatient monitoring of wound healing. Among all TJA, there was no significant association in the rate of PJI requiring return to the OR between groups.ConclusionsAlthough betadine is cost-effective and has been shown to reduce PJI rates, there remains concerns in the literature over soft tissue toxicity and wound healing. This study suggests CHG may be as efficacious as dilute betadine in preventing PJI while also decreasing the risk of superficial drainage and wound complications needing unplanned ER visits during the acute postoperative period.

Incidence and risk factors for periprosthetic joint infection: A common data model analysis.

Objectives The aim of this study was to determine the incidence of periprosthetic joint infection (PJI) following primary total joint arthroplasty (TJA) and to investigate risk factors in a large cohort utilizing common data model (CDM).Patients and methods The entire cohort of primary and revision hip or knee TJA between January 2003 and December 2017 was retrospectively analyzed utilizing the CDM database. We detected patients who had revision TJA as a consequence of PJI. We determined the incidence of PJI and examined risk factors, including demographic features, comorbidities, prior corticosteroid usage, and preoperative laboratory values.Results There were 34 revision TJAs as a consequence of PJI (hip, 16; knee, 18) among 12,320 primary TJAs (hip, 4,758; knee 7,562), representing 0.27% incidence of PJI (hip, 0.33%; knee 0.23%). Of the patients, 15 were males and 19 were females. The mean age at the time of primary TJA was 59.8±17.5 (range, 31 to 85) years in hip PJI patients and 71.4±7.2 (range, 56 to 80) years in knee PJI patients. Hypertension and urinary tract infection were both associated with PJI following primary hip TJA. Age between 70 and 79 years, male sex, urinary tract infection, anemia, and prior corticosteroid usage were all associated with PJI following primary knee TJA.Conclusion This study indicates the viability of employing CDM to undertake research on PJI and serves as a reference for future CDM-based risk factor analysis. Preoperative screening and mitigating identified risk factors can aid in the reduction of PJI following TJA.

Emergency department visits following total joint arthroplasty: do revisions present a higher burden?

AimsAlthough readmission has historically been of primary interest, emergency department (ED) visits are increasingly a point of focus and can serve as a potentially unnecessary gateway to readmission. This study aims to analyze the difference between primary and revision total joint arthroplasty (TJA) cases in terms of the rate and reasons associated with 90-day ED visits.MethodsWe retrospectively reviewed all patients who underwent TJA from 2011 to 2021 at a single, large, tertiary urban institution. Patients were separated into two cohorts based on whether they underwent primary or revision TJA (rTJA). Outcomes of interest included ED visit within 90-days of surgery, as well as reasons for ED visit and readmission rate. Multivariable logistic regressions were performed to compare the two groups while accounting for all statistically significant demographic variables.ResultsOverall, 28,033 patients were included, of whom 24,930 (89%) underwent primary and 3,103 (11%) underwent rTJA. The overall rate of 90-day ED visits was significantly lower for patients who underwent primary TJA in comparison to those who underwent rTJA (3.9% vs 7.0%; p < 0.001). Among those who presented to the ED, the readmission rate was statistically lower for patients who underwent primary TJA compared to rTJA (23.5% vs 32.1%; p < 0.001).ConclusionED visits present a significant burden to the healthcare system. Patients who undergo rTJA are more likely to present to the ED within 90 days following surgery compared to primary TJA patients. However, among patients in both cohorts who visited the ED, three-quarters did not require readmission. Future efforts should aim to develop cost-effective and patient-centred interventions that can aid in reducing preventable ED visits following TJA.Cite this article: Bone Jt Open 2022;3(7):543–548.

The Significance of Race/Ethnicity and Income in Predicting Preoperative Patient-Reported Outcome Measures in Primary Total Joint Arthroplasty.

Utilization of total joint arthroplasty (TJA) by minorities is disproportionately low compared to Whites. Contributing factors include poorer outcomes, lower expectations, and decreased access to care. This study aimed to evaluate if race and income were predictive of preoperative patient-reported outcome measures (PROMs) and the likelihood of achieving the minimal clinically important difference (MCID) following TJA. We retrospectively reviewed 1,371 patients who underwent primary TJA between January 2018 and March 2021 in a single healthcare system. Preoperative and postoperative PROM scores were collected for Patient-Reported Outcomes Measurement Information System (PROMIS) Mental Health, PROMIS Physical Function (PF10a), and either Knee injury and Osteoarthritis Outcome Score (KOOS) or Hip disability and Osteoarthritis Outcome Score (HOOS). Demographic and comorbidity data were included as explanatory variables. Multivariable regression was used to analyze the association between predictive variables and PROM scores. Mean preoperative PROM scores were lower for non-Whites compared to Whites. Increased median household income was associated with higher preoperative PROM scores. Non-White race was associated with lower PROMIS Mental Health and KOOS, but not PF10a or HOOS scores. Only non-White race was associated with a decreased likelihood of achieving MCID for PF10a. Neither race nor income was predictive of achieving MCID for KOOS and HOOS. Non-White race/ethnicity and lower income were associated with lower preoperative PROMs prior to primary TJA. Continued research is necessary to identify the causes of this discrepancy and correct this disparity.

Social Needs of Patients Undergoing Total Joint Arthroplasty.

Many patients have unmet social needs that may affect their health care utilization and outcomes. We sought to examine a program to determine the types of social needs facing arthroplasty patients and methods used to address these needs. We conducted a pilot, retrospective review of our integrated social needs program for total joint arthroplasty (TJA) patients. A 16-question needs assessment was instituted as part of our perioperative protocol between February 1, 2020, to October 1, 2020. We examined the types of social needs in 250 primary TJA patients and a resolution method. We evaluated associations between social needs and demographics and Area Deprivation Index (ADI). Outcome measures were also evaluated, including readmissions, discharge date, and outcome score changes. Forty-four (17.6%) patients had a social need. Social needs frequency increased in non-White patients (P ≤ .0001), non-English speakers (P= .0304), younger patients (P= .001), nonmarried patients (P= .0006), unemployed patients (P= .0189), and patients with less health literacy (P= .0215). ADI scores were positively associated with social needs at the national (P= .0006) and state levels (P=.0004). Overall, 75.9% of needs centered around utility payments, employment, prescription costs, education, and transportation. In addition, 64% of the identified needs were resolved through outside referrals. Ninety-day readmissions were significantly higher in patients with social needs (P= .0087). Overall, 17.6% of patients in our state have social needs before TJA. Factors increasing the risk of social needs include younger age, minority race, single or divorced marital status, unemployment, low health literacy, and higher ADI. The 90-day readmission rate was significantly higher in patients with social needs.

Antimicrobial Stewardship in Total Joint Arthroplasty: Outcomes of a Collaborative Program Implementation.

Antimicrobial stewardship has been cited as a crucial component of orthopaedic surgical care; however, limited high-quality data exist to guide antibiotic use across the total joint arthroplasty continuum. Antimicrobial stewardship program (ASP) implementation and evaluation is needed in this space. We pursued a prospective, sequential cohort study of an interprofessional ASP for total joint arthroplasty (TJA) formed in late 2017 at the study institution. Twelve total evidence-based recommendations for protocol change were issued, with 11 accepted and implemented across three project phases spanning March 2018 to December 2019. The primary study outcome was the rate of optimal preoperative intravenous antibiotic selection as assessed for Baseline versus Postintervention time periods. Secondary outcomes included individual antibiotic utilization rates. Descriptive statistics were pursued for institutional surgical site infection (SSI) and postoperative acute kidney injury (AKI) rates across the affected time frame. A cost-benefit analysis of the ASP was estimated from the institutional perspective. The rate of optimal preoperative antibiotic selection increased from 64.9% in the Baseline Period (February 2018, n = 57) to 95.4% in the Postimplementation period (June 2018 to December 2019, n = 1,220) (P < 0.001). The rates of second-line preoperative antibiotics and total perioperative antibiotic exposures decreased. Total SSI and AKI rates in primary elective TJA seemed to decrease from calendar year 2018 to 2019 (deep SSI 1.00% to 0.22%, superficial SSI 0.66% to 0.00%, and AKI 1.97% to 1.03%). The institution realized an estimated $197,050 cost savings per 1000 TJA procedures. A comprehensive ASP for TJA was associated with an increased use of optimal preoperative antibiotic selection, decreased total antibiotic exposures, and cost savings, without apparent detriment to SSI or AKI rates.

The utility of machine learning algorithms for the prediction of patient-reported outcome measures following primary hip and knee total joint arthroplasty.

Patient-reported outcome measures (PROMs) are increasingly used as quality benchmark in total hip and knee arthroplasty (THA; TKA) due to bundled payment systems that aim to provide a patient-centered, value-based treatment approach. However, there is a paucity of predictive tools for postoperative PROMs. Therefore, this study aimed to develop and validate machine learning models for the prediction of numerous patient-reported outcome measures following primary hip and knee total joint arthroplasty. A total of 4526 consecutive patients (2137 THA; 2389 TKA) who underwent primary hip and knee total joint arthroplasty and completed both pre- and postoperative PROM scores was evaluated in this study. The following PROM scores were included for analysis: HOOS-PS, KOOS-PS, Physical Function SF10A, PROMIS SF Physical and PROMIS SF Mental. Patient charts were manually reviewed to identify patient demographics and surgical variables associated with postoperative PROM scores. Four machine learning algorithms were developed to predict postoperative PROMs following hip and knee total joint arthroplasty. Model assessment was performed through discrimination, calibration and decision curve analysis. The factors most significantly associated with the prediction of postoperative PROMs include preoperative PROM scores, Charlson Comorbidity Index, American Society of Anaesthesiology score, insurance status, age, length of hospital stay, body mass index and ethnicity. The four machine learning models all achieved excellent performance across discrimination (AUC > 0.83), calibration and decision curve analysis. This study developed machine learning models for the prediction of patient-reported outcome measures at 1-year following primary hip and knee total joint arthroplasty. The study findings show excellent performance on discrimination, calibration and decision curve analysis for all four machine learning models, highlighting the potential of these models in clinical practice to inform patients prior to surgery regarding their expectations of postoperative functional outcomes following primary hip and knee total joint arthroplasty. Level III, case control retrospective analysis.

CO81 Episode of Care Assurance Program (ECAP) Results in Significantly Reduced Readmissions for Patients Undergoing Primary Total Joint Replacement Surgery

The leading cause of total joint arthroplasty (TJA) readmission is wound complications with national average readmission rate of 5.3%, and mean cost of $27,979 per hospital stay. The study aimed to evaluate the impact of eCAP, a warranty system for using Smith+Nephew’s Primary Total Hip or Knee System with Oxinium + Single Use Negative Pressure Wound Therapy + Antimicrobial Silver Dressing together in 44 hospital facilities who have implemented it, compared to non-eCAP facilities for readmissions in patients undergoing primary TJA surgery.

Less Than One-third of Hospitals Provide Compliant Price Transparency Information for Total Joint Arthroplasty Procedures.

The Centers for Medicare and Medicaid Services (CMS) recently implemented price transparency legislation. As total joint arthroplasty (TJA) procedures are widely used, expensive, and generally are predictable in terms of cost and expected outcomes, these procedures are a proxy for assessing how hospitals provide price transparency for their services as a whole. Furthermore, cost estimates for TJA procedures represent some of the most commonly sought-after price transparency information among the orthopaedic surgery patient population. We asked: (1) Are hospitals compliant with federal rules mandating transparency in pricing for primary TJA? (2) Are hospitals providing these data in a user-friendly format? (3) Is there a difference in prices quoted based on Current Procedural Terminology (CPT) codes compared with Diagnosis Related Group (DRG) codes? Our cross-sectional retrospective analysis used the CMS's Hospital Compare database. This database includes information for 5326 Medicare hospitals nationally. We excluded children's, psychiatric, Veterans Affairs, and active military base hospitals as well as hospitals performing fewer than 100 TJAs annually. A total of 1719 hospitals remained after this selection process. Random sampling stratified across practice setting, hospital size, TJA volume, type, ownership, and Census region was performed to identify 400 facilities for our final analysis. Included hospitals were located predominately in urban areas (79% [317 of 400]) and were mostly medium-sized facilities (43% [171 of 400]). Most hospitals were classified as acute care (98% [392 of 400]) versus critical access. Three reviewers thoroughly searched each hospital website for a machine-readable file providing the following five datapoints: gross charges, payer-specific negotiated charges, deidentified minimum negotiated charges, deidentified maximum negotiated charges, and discounted cash prices. Hospitals that provided all five datapoints through a machine-readable file were considered compliant. Additionally, we considered hospitals with any gross price information pseudocompliant. The consumer-friendliness of the website was assessed based on the following criteria: (1) languages other than English were offered, (2) it took less than 15 minutes to locate pricing information, (3) a phone number or email address was provided for questions, and (4) there was a description of procedure in common terms. Pricing information was recorded and compared for CPT codes 27447 and 27130 and DRG codes 469 and 470. Data were sourced from December 1 through 20, 2021, to assess compliance in the first year since the legislation was implemented. Only 32% (129 of 400) of the sampled hospital websites were compliant with all six requirements under the CMS rule for transparency in pricing. When segregating by individual procedures, 21% (84 of 400), 18% (72 of 400), 18% (71 of 400), and 19% (74 of 400) of hospitals provided CMS-compliant pricing information for CPT codes 27447 and 27130 and DRG codes 469 and 470, respectively. For each code, rates of pseudocompliance were 36% (143 of 400), 31% (125 of 400), 34% (135 of 400), and 50% (199 of 400) for the included codes, respectively. Most included hospitals provided at least some of their pricing data in a user-friendly format. Prices quoted using a DRG search were higher overall than prices quoted using a procedure-specific CPT code. Although the CMS implemented a price transparency mandate at the beginning of 2021, our analysis demonstrated that most hospitals either do not provide TJA price estimates or are noncompliant when presenting related information. Specifically, approximately half of evaluated hospitals provided a gross charge for any TJA code, and less than one-third of these institutions were fully compliant with all CMS mandates for these procedures. Given the potential influence compliance and price sharing may have on empowering patients' healthcare decisions and reducing healthcare expenditures, hospitals should use our analysis to identify where their compliance is lacking and to understand how to make their pricing information more readily available to their patients. In addition to ensuring that all six CMS mandates are met, this should include providing information in easy-to-understand formats and making related services identifiable across all levels of health literacy. Furthermore, we advocate for the use of CPT codes and layman terms when identifying provided services as well as a price estimator tool that allows for the download of a machine-readable file specific to the procedure of interest.

Pharmacological thromboprophylaxis as a risk factor for early periprosthetic joint infection following primary total joint arthroplasty

Venous thromboembolism (VTE) prophylaxis has been suggested for patients who underwent total join arthroplasty (TJA). However, the morbidity of surgical site complications (SSC) and periprosthetic joint infection (PJI) has not been well evaluated. We aimed to evaluate the impact of VTE prophylaxis on the risk of early postoperative SSC and PJI in a Taiwanese population. We retrospectively reviewed 7511 patients who underwent primary TJA performed by a single surgeon from 2010 through 2019. We evaluated the rates of SSC and PJI in the early postoperative period (30-day, 90-day) as well as 1-year reoperations. Multivariate regression analysis was used to identify possible risk factors associated with SSC and PJI, including age, sex, WHO classification of weight status, smoking, diabetes mellitus (DM), rheumatoid arthritis(RA), Charlson comorbidity index (CCI), history of VTE, presence of varicose veins, total knee or hip arthroplasty procedure, unilateral or bilateral procedure, or receiving VTE prophylaxis or blood transfusion. The overall 90-day rates of SSC and PJI were 1.1% (N = 80) and 0.2% (N = 16). VTE prophylaxis was a risk factor for 90-day readmission for SSC (aOR: 1.753, 95% CI 1.081–2.842), 90-day readmission for PJI (aOR: 3.267, 95% CI 1.026–10.402) and all 90-day PJI events (aOR: 3.222, 95% CI 1.200–8.656). Other risk factors included DM, underweight, obesity, bilateral TJA procedure, younger age, male sex and RA. Pharmacological thromboprophylaxis appears to be a modifiable risk factor for SSC and PJI in the early postoperative period. The increased infection risk should be carefully weighed in patients who received pharmacological VTE prophylaxis.

Characterization and Potential Relevance of Randomized Controlled Trial Patient Populations in Total Joint Arthroplasty in the United States: A Systematic Review

BackgroundA substantial number of randomized controlled trial (RCT) studies in total joint arthroplasty (TJA) are published each year in the United States (US). However, it is unknown how closely the demographic and clinical characteristics of these cohorts resemble that of the US patient population undergoing TJA. Thus, the purpose of this systematic review was to evaluate the patient characteristics of published RCTs in TJA in the US and to compare these characteristics against patient cohorts from national patient databases. MethodsRCT studies regarding primary TJA conducted in the US were selected. Key patient demographics were aggregated and compared against demographics characteristics of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality National Inpatient Sample (NIS) and American College of Surgeons National Surgical Quality Improvement Program patient cohorts. ResultsOne hundred and fifty-three RCTs fulfilled the inclusion criteria and were included. The total number of patients in the 153 RCTs was 24,135 patients. The average age of patients in the TJA RCT cohort was 65 years (53-80) while the NIS cohort was 67 years (18-90) (d = 0.21, effect size = small). The average body mass index of the TJA RCT cohort was 30.8 (18.2-37.6) while the National Surgical Quality Improvement Program cohort was 31.9 (14.1-59.6) (d = 0.18, effect size = small). For TJA, effect sizes for age, body mass index BMI, sex, ethnicity, smoking, and diabetes were all small or very small. ConclusionOverall, the US RCT patient cohort for TJA does not differ substantially from the general patient population undergoing TJA in the United States. Differences in demographic and clinical characteristics between the TJA RCT cohort and database cohorts ranged from minimal to small, suggesting that these differences are unlikely to impact clinical outcomes.